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ORIGINAL ARTICLE

Dual Diagnosis and Suicide Probability in Poly-Drug Users Ismail M. Youssef1, Magda T. Fahmy1, Wafaa L. Haggag1, Khalid A. Mohamed1 and Amany A. Baalash2

ABSTRACT

Objective: To determine the frequency of suicidal thoughts and suicidal probability among poly-substance abusers in Saudi population, and to examine the relation between dual diagnosis and suicidal thoughts. Study Design: Case control study. Place and Duration of Study: Al-Baha Psychiatric Hospital, Saudi Arabia, from May 2011 to June 2012. Methodology: Participants were 239 subjects, aged 18 - 45 years. We reviewed 122 individuals who fulfilled the DSM-IV-TR criteria of substance abuse for two or more substances, and their data were compared with that collected from 117 control persons. Results: Suicidal cases were highly present among poly-substance abusers 64.75%. Amphetamine and cannabis were the most abused substances, (87.7% and 70.49%, respectively). A statistically significant association with suicidality was found with longer duration of substance abuse (p < 0.001), using alcohol (p=0.001), amphetamine (p=0.007), volatile substances (p=0.034), presence of comorbid psychiatric disorders (dual diagnosis) as substance induced mood disorder (p=0.001), schizo-affective disorder (p=0.017), major depressive disorders (p=0.001), antisocial (p=0.016) and borderline (p=0.005) personality disorder. Suicidal cases showed significant higher scores (p < 0.001) of suicide probability scale and higher scores in Beck depressive inventory (p < 0.001). Conclusion: Abusing certain substances for long duration, in addition to comorbid psychiatric disorders especially with disturbed-mood element, may trigger suicidal thoughts in poly-substance abusers. Depression and suicide probability is common consequences of substance abuse. Key Words: Beck depressive inventory. Depression. Dual diagnosis. Poly-drug abuse. Suicidal thoughts. Suicide probability scale.

INTRODUCTION

Prevalence of actual substance abuse among youths has nearly doubled over the past decade.1 Substance abuse is associated with suicidal ideation and suicide. This is attributed to the intoxicating and disinhibiting effects of many psychoactive substances.2 Suicide rates are increasing all over the world including Saudi Arabia.3 Beck (1986) defined suicidal ideation as the presence of thoughts or contemplation about suicide or a wish of an individual to terminate his or her life, but there is no self destructive action related to these thoughts.4 Suicidal thoughts and behaviors are a significant indicator of other co-occurring disorders.5 So, psychiatric comorbidity with substance use increases the risk for suicidal behavior.6 Assessment of these links is important to identify predictors for suicide in substance abusers to develop specific interventions for persons in substance abuse treatment. 1 2

Department of Neuropsychiatry, Suez Canal University, Ismailia, Egypt. Department of Psychiatry, Psychiatric Hospital, Al-Baha, Saudi Arabia.

Correspondence: Dr. Amany A. Baalash, Department of Psychiatry, Psychiatric Hospital, Al-Baha, Baljurashi 22888, P. O. Box 14, Saudi Arabia. E-mail: [email protected] Received: August 16, 2014; Accepted: October 28, 2015. 130

The objective of this study was to examine the relation between dual diagnosis and suicidal thoughts, investigate probability of suicide and severity of depression in suicidal substance abusers.

METHODOLOGY

This case-control study was conducted at Al-Baha Psychiatric Hospital in Saudi Arabia, from May 2011 to June 2012. The presumptive prevalence of substance abuse among this study population was 7.8%.7 The calculated sample size per group was around 122 according to the following equation: n = (z/e)

2

(p) (1 - p)

Where, n = the sample size per group, p = the expected prevalence = 7.8%, z = the critical value which determines the area underlying the 95% of population on the normal distribution curve = 1.96, and e = the margin of sample error tolerated = 0.05; so that n = (1.96/0.05)2 x (0.078) x (1- 0.078) = 111. The expected drop-out was 10%, so the total sample size was taken as 122. Cases (n=122) were identified as male in-patient, aged 18 - 45 years, who met the criteria of diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV-TR) for psychiatric diagnosis of substance abuse, and who were abusing two or more substances. They were assessed after the period of de-toxification and withdrawal. Patients were classified into suicidal and non-suicidal according to the presence of a lifetime history of suicidal ideation or attempt (Grohol 2012).8

Journal of the College of Physicians and Surgeons Pakistan 2016, Vol. 26 (2): 130-133

Dual diagnosis and suicide probability in poly-drug users

The controls (n=117) are male subjects who never had the experience of taking illicit substances, and not suffering from any current or past-psychiatric disorders or serious medical disease. Controls were matched for age and residential environment and chosen from employees, workers in the hospital, and their relatives and friends. Sample was selected by systematic random sampling. There are about 225 - 273 cases suffering polysubstance abuse admitted to the hospital yearly, while the sample size was 122, so the interval was taken as 273/122 = 2, calculated as K=N/n, where “K” is the interval, “n” is the sample size, and “N” is the population size. The first case was chosen randomly then every 2nd case was selected to fulfill the required sample size, which is 122 cases.

Written informed consents were obtained from the participants. Information from family members were gathered in some cases. Participants were examined after detoxification and were subjected to psychiatric history and mental state examination. Full physical, neurological examination, routine laboratory tests (CBC, blood chemistry {blood glucose level, renal function test, liver function test, serum electrolyte, and lipid profile}, and urine analysis), urine and blood toxicology screen {for opioid, amphetamine, alcohol, cannabis, benzodiazepine, and barbiturate} and ECG were done in order to exclude serious organic pathology. Modified semi-structured Questionnaire for the drug intake and the assessment of socio-demographic data9 was used. Additionally, a suitable semi-constructed interview of modified Ain Shams University case sheet10 was also conducted. The standardized Arabic versions of suicidal probability scale for assessment of suicidal probability11 and of Beck Depression Inventory Scale (BDI) for quantitative assessment of the intensity of depression12 were used.

The collected data were organized, tabulated and statistically analyzed using software statistical computer package (SPSS) version 16. For quantitative data, the mean and standard deviation were calculated. For qualitative data, comparison between the groups was done using chi-square test (χ2). For comparison between mean values of two groups of parametric data, student t-test was used. For comparison between more than two mean values, the F-value of analysis of variance (ANOVA) was calculated, where Tamhane`s T2 test for unequal variances was performed to compare each two means, if F-value was significant. For all tests, p-value less than 0.05 was considered as statistically significant.

RESULTS

The sample consisted of 122 cases (79 suicidal cases and 43 non-suicidal cases) and 117 controls. Five participants from the control group were considered as

drop-out because they did not finish the psychometric tests. Suicidal thought and probability was high among poly-substance users (64.75%), and (22.13%) of cases have history of at least one suicide attempt. The difference between mean age of all cases (31.35 ±6.25) and controls (31.66 ±7.84) was not significant (p= 0.74). Table I shows that one way ANOVA test revealed significantly lower (p=0.003) mean age of non-suicidal group (28.47 ±5.78) than that of the mean age of the other two groups (suicidal 32.92 ±5.95, controls 31.66 ±7.84) confirmed by post-hoc test (Tamhane's T2). Table II shows that amphetamine and cannabis dominated the list of substances abused in the present study. Amphetamine was the most commonly abused substance (87.7%), followed by cannabis abuse (70.49%). Amphetamine (p=0.007), alcohol (p=0.001) and volatile substances (p=0.034) were significantly higher in suicidal cases than non-suicidal.

Thirty-nine patients (31.97%) started substance use before the age of 18 years. There was no significant association between the age of beginning of substance abuse and suicidal thoughts or behaviors. But duration of substance intake was very high, significantly associated with suicidal thoughts or behavior (p < 0.001). Table III shows that co-morbidity of substance abuse with another mental illness (dual diagnosis) was well established in 101 cases (82.79%) diagnosed as schizophrenia (16.39%), schizo-affective disorder (2.46%), bipolar-I disorder (16.39%), major depressive Table I: Age of participants. Age

Controls (n=117) Mean (±SD)

31.66 ±7.84

According to post hoc tests:

Cases (n=122)

Non-suicidal (n = 43)

Mean (±SD) 28.47 ±5.78

Suicidal

p-value

(n = 79)

Mean (±SD)

32.92 ±5.95

0.003**a,c

a = Statistical significant difference between control and non-suicidal groups. b = Statistical significant difference between control and suicidal groups c = Statistical significant difference between non-suicidal and suicidal groups *p-value